Download MBBS (Bachelor of Medicine and Bachelor of Surgery) Latest Acute Pancreatitis Lecture PPT
PANCREATITIS.
DR. P.C. Mishra,MD.
ACUTEPANCREATITIS.
? An acute condition presenting with abdominal
pain usually associated with raised
blood/urine pancreatic enzyme as a result of
pancreatic inflammation.
? Reversible pancreatic parenchymal injury
associated with inflammation.
ACUTE PANCREATITIS.
? PATHOPHYSIOLOGY?
? Premature activation of
pancreatic enzymes within the pancreas.
? Anything that injures the acinar cells and impairs
the secretion of zymogen granules or damages
the duct epithelium and thus delays enzymatic
secretion , can trigger acute pancreatitis.
? Once cellular injury has been initiated , the
inflammatory process can lead to pancreatic
oedema, haemorrhage, and eventually necrosis.
ETIOLOGY.
? acute pancreatitis-
? As an acute inflammatory process of the
pancreas with variable involvement of other regional
tissues or remote organ system.
? Two major causes are--
? Biliary calculi(50-70%)
? Alcohol abuse (25%).
? The remaining causes may be idiopathic or rare.
? Approx. 25 % cases of Acute pancreatitis.
? Act by increasing the synthesis of enzymes by
pancreatic acinar cells.
? Over-sensitization of acini to cholecystokinin.
? SMOKING-
? cigarette smoking is an independent
risk factor for acute and chronic pancreatitis.
HYPERTRIGLYCERIDEMIA.
? Serum concentration above 1000 mg/dl ppt. Attacks of
acute pancreatitis.
? A triglyceride level higher than 2000 mg/dl confirm the
diagnosis of acute pancreatitis.
? Hypercalcemia-
Hypercalcemia of any cause can lead to acute
pancreatitis.
? Deposition of calcium in the pancreatic duct and calcium
activation of trypsinogen within the pancreatic parenchyma.
Causes of Acute pancreatitis.
? Gall stone.
? Alcoholism.
? Abdominal trauma.
? Hyperparathyroidism.
? Hypercalcaemia.
? Autoimmune pancreatitis.
? Viral infection.
Gall stone pancreatitis.
? Transient blockage of common bile duct--
reflux of bile into pancreatic duct and impair
flow of normal pancreatic juice ?premature
activation of pancreatic enzymes within duct
system.
CLINICALLY.
? Presenting with 2 of the following 3 criteria
? Epigastric pain consistent with pancreatitis.
? Serum amylase or lipase level greater than 3
times the upper limit of normal.
? Radiologic imaging consistent with pancreatitis(
usually CT or MRI ).
HISTORY TAKING.
? 1.Abdominal pain-
? Site-Diffuse,upperabdominalpain.
? Onset--sudden.
? Character?Boringpain.
? Radiation---Radiatetoback.
? Associatedfactor-Nausea,vomiting...
? Timing--Painescalatesinintensityandpeakswithin
10-20minutesofonset.
? Elevationoftemperatureisoftenisacute
pancreatitis.
Abdominal Examination.
? 1.Inspection-- abdominal distension.
? 2.Palpation--
? Hepatomegally.
? Tenderness.
? Cullen sign.(Blue
discoloration around umblicus)
? Gray turner sign. ( Blue red
purple discoloration around flank).
? Peritoneal sign
? Rigidity and Guarding.
? Percussion--
? Dullness suggesting ascites.
Auscultaion-
? ascultate the abdomen for hypoactive
or an absent bowel sound.
INVESTIGATION.
? Biochemical---
? Serum Amylase increase 3x than
normal or more than 1000IU/mL.( Peak within
the first 24 hrs after onset of symptom.
? Serum lipase has longer half life thus more
useful in delayed case.
? Serum lipase: more sensitive and specific for
pancreatitis than Amylase.
Amylase and Lipase.
? Elevated serum amylase and Lipase levels in
combination with severe abdominal pain. Often
trigger the initial diagnosis of acute pancreatitis.
? Serum lipase rises 4 to 8 hrs from the onset of
symptoms and normalise within 7 to 14 days
after treatment.
? Marked elevation of serum amylase level during
24 hrs.
? If lipase level is about 2.5 to 3 times that of
Amylase, it is an indication of pancreatitis due to
Alcohol or gall stone.
Biochemical investigation.
? Serum amylase-
? Levels turn normal after 48-72 hrs even
with the continuing of pancreatitis, serum lipase should be sent
that remains high for 7-14 days.
? Persistent elevation suggests pseudocyst,
pancreatic abscess or non pancreatic
cause(intestinal obstruction, mumps,narcotics).
? Serum lipase- Remains elevated for 7-14 days. It is diagnostic.
Serum Lipase.
? The sensitivity of serum lipase is similar to that
of serum Amylase and is between 85% to
100%.
? Lipase may have greater specificity for
pancreatitis than amylase.
? Serum lipase always is elevated on the first
day of illness and remains elevated longer
than does the serum amylase.
Other laboratory Findings.
WBC- 15000----30OOO
Leucocytosis
GLUCOSE HIGH
Hyperglycemia in severe cases.
BUN MAY BE ELEVATED
SERUM CALCIUM MAY BE LOW IN 25% OF CASES.
AST,BILIRUBIN,ALP ARE TRANSIENTLY ELEVATED,ALBUMIN IS LOW IN
10% OF CASES AND INDICATE SEVERE PANCREATITIS
ELEVATED LDH SUGGEST POOR PROGNOSIS
and indicate biliary tract disease.
Assesment of C-reactive Good indicator of progress.
ABG shows HYPOXIA.
Other cause of increased serum
Amylase.
? Renal failure.
? Liver cirrhosis.
? Peritonitis.
? Ruptured ectopic pregnancy.
? Salivary gland inflammation(parotitis).
other blood test.
FULL BLOOD COUNT
Elevated Leucocyte count for Ranson's
criteria and to predict prognosis.
LFT
To asses cause of pancreatitis/obstructive
jaundice.
Random blood glucose
Damage to beta cells interferes with insulin
production causing Hyperglycemia( in severe
cases).
Serum calcium
Hypocalcaemia suggest saponification.
Ranson score
predicting the severity of acute pancreatitis.
? At admission
. age in years > 55
? WBC count > 16000 cells/mm3.
? Blood glucose > 200 mg/dl
? Serum AST > 250 IU/L
? Serum LDH > 350 IU/L
? At 48 hrs
? Calcium- < 8 mg/dl
? Hypoxia (po2 < 60mmHg)
? Increased BUN
IMAGING ?ULTRASOUND.
? USG should be performed within 24 hrs in all
patient.
? To detect--- Gallstones.
? To rule out-- Acute Cholecystitis.
? To determine whether the common bile duct
is dilated.
? To evaluate change on pancreas i.e. Edema.
Mass in pancreas.
CT SCAN.
? Not neccessary for all patients.
? May reveal pseudocyst or
abscess.(complication of acute pancreatitis).
? CT Findings--
? significant swelling and
inflammation of the pancreas.
Management Acute pancreatitis.
? Mild Acute pancreatitis--
? 1.Nill by mouth.
? 2.Fluid resuscitation-4 pint.
? 3.Analgesia-IM Tramal 50mg TDS.
? 4.Treat underlying cause.
? 5. NO role of antibiotic.
Severe Acute Pancreatitis.
? Admission to ICU.
? Oxygen supplementation.
? Analgesia.
? Aggressive fluid rehydration.
? Monitor vital sign.
? Monitor haematological and biochemical
parameters.
? Nasogastric drainage.
? Antibiotic prophylaxis--imipenem, cefuroxime.
CASE 1.
? 56-years-old obese man who is in cardio-
respiratory distress. While reviewing the
patients record you see that he has a four-yrs
h/o alcohol abuse and he was admitted to the
hospital via the emergency room 36 hrs
previously with a two day h/o Epigastric pain
and vomiting.........
On admission vital sign..
? Blood pressure-------95/30
? Pulse rate -------110/min
? Respiratory rate -----28 breath/min.
? temp. ------38.6
? Abdomen was distended and diffusely tender.
? No Bowel sound were heard.
Laboratory data included:
? WBC count----18,000/ml
? Blood glucose---220 mg/dl
? Calcium -------- 7 mg/dl
? Creatinine -----2 mg/dl
? LDH -----980 IU/l
? CRP ------15 mg/dl
? Amylase ---180 IU/l
? Lipase 1540 IU/l
? The serum was Lipemic.
This post was last modified on 30 November 2021